How can CVA risk be reduced?

Strategies to Reduce Cerebrovascular Accident (CVA) Risk

The most effective way to reduce CVA risk is through a comprehensive approach targeting modifiable risk factors including diet, physical activity, blood pressure control, lipid management, and lifestyle modifications.

Dietary and Lifestyle Modifications

• Consume a diet rich in vegetables and fruits, which has been associated with lower risk of developing cardiovascular disease, particularly stroke 1
• Increase fiber intake by eating beans, whole-grain products, fruits, and vegetables 1
• Use liquid vegetable oils in place of solid fats and limit foods high in added sugars 1
• Choose foods made with whole grains and reduce salt intake by selecting products with less sodium 1
• Select low-fat dairy products and lean cuts of meat, removing skin from poultry before eating 1
• If consuming alcohol, limit intake to no more than 1 drink per day for women and 2 drinks per day for men 1
• Maintain appropriate weight through diet and physical activity to reduce obesity-related CVA risk 1, 2

Blood Pressure Management

• Screen for and aggressively manage hypertension, which is a major modifiable risk factor for stroke 3
• Regular blood pressure monitoring and appropriate medication management are essential for CVA prevention 1
• Consider carotid artery ultrasound in high-risk populations (patients with hypertension, obesity, or diabetes who received >40 Gy radiation to the neck) 1

Lipid Management

• Statin therapy is recommended for appropriate patients based on risk stratification 1, 4
• For patients with established cardiovascular disease, high-intensity statin therapy is recommended to reduce CVA risk 1
• Consider plant stanols/sterols (up to 2g/day) as a therapeutic option to lower LDL cholesterol by up to 15% 1
• Monitor for elevated lipoprotein(a) [Lp(a)], which is associated with increased risk of stroke, particularly in pediatric patients 1

Diabetes Management

• Screen for altered glucose metabolism as part of regular care, with screening repeated every 3 years 1
• For patients with type 2 diabetes, consider GLP-1 receptor agonists that have demonstrated cardiovascular benefits including reduction in stroke risk 1
• Several GLP-1RAs have been shown to reduce the risk of MI, CVA, or CV death in adults with T2D and cardiovascular disease 1

Special Populations

Cancer Survivors

• Cancer survivors, particularly those who received cranial radiation therapy, have significantly higher risk of CVA 1
• Leukemia survivors are 6 times more likely to experience CVA compared to siblings, while brain tumor survivors are 29 times more likely 1
• Survivors who received >50 Gy to the prepontine cistern have a hazard ratio of 17.8 for death from cerebrovascular disease 1
• Hodgkin lymphoma survivors treated with radiation to the neck and mediastinum have 2.5 times higher risk of ischemic cerebrovascular disease 1

Secondary Prevention

• Among patients with established vascular disease, there is substantial variation in estimated 10-year risk of recurrent vascular events (from <10% to >30%) 1
• Even with optimal treatment, many patients with vascular disease will remain at >20% and even >30% 10-year risk, indicating an area of unmet medical need 1
• For secondary prevention, consider anticoagulation therapy with direct oral anticoagulants (DOACs) for appropriate patients with ischemic stroke 3

Risk Assessment and Stratification

• Consider age and sex in CVA risk assessment, as increasing age and male sex increase CVD risk 1
• Recognize that relatively young people may be at low absolute risk despite having multiple risk factors, but their relative risk may be significantly elevated 1
• Traditional risk factors (smoking, hypertension, diabetes, dyslipidemia) explain one-third to one-half of age differences in coronary heart disease risk 1

Monitoring and Follow-up

• Regular monitoring of cardiovascular risk factors is essential for ongoing CVA risk reduction 3
• For patients with established CVD, regular assessment of residual risk factors can help guide therapy intensification 5
• Consider specialized rehabilitation for patients who have experienced a CVA, including cognitive, physical, and speech therapy as appropriate 3

Common Pitfalls to Avoid

• Underestimating CVA risk in women - cardiovascular disease is the biggest cause of death in women 1
• Failing to address multiple risk factors simultaneously - a comprehensive approach is more effective than focusing on single risk factors 2
• Neglecting to screen for and manage comorbidities that increase stroke risk, such as atrial fibrillation 6
• Overlooking the increased CVA risk in specific populations such as cancer survivors who received radiation therapy 1
• Assuming all patients with vascular disease have the same risk level - risk stratification is essential for appropriate management 1